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RN Staffing and Patient Outcomes

Monday October 8, 2007
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Nurse leaders have traditionally relied on experience and intuition to staff nurses at levels needed to provide adequate care to patients. Administrators, on the other hand, favor hard data over intuition, especially when it comes to making changes like increasing staff and purchasing new equipment.

"The folks in upper management don't want to know what you think or feel," says Karen F. Griffin, MSN, RN, CNAA, a nurse administrator in Texas. "They want hard data. We're painting a picture of why we need more staff or why we need more computers."

The "we" in this instance is Griffin and her colleagues at the San Antonio-based South Texas Veterans Healthcare System (STVHS), where Griffin works as associate chief nurse for ambulatory care. The staff, which serves veterans in a 62-county region, uses a model developed in recent years that compares nurse-sensitive performance indicators with workload indicators to demonstrate and justify to administrators changes in nurse staffing, equipment purchases, processes, and workflow.

The model that the STVHS staff developed got its start in September 2001 and was implemented in 2002 and 2003 in an effort to improve quality of care, says Beth Ann Swan, PhD, CRNP, FAAN. Swan, associate dean for nursing graduate programs at Thomas Jefferson University in Philadelphia, co-authored an article with Griffin on the STVHS model.

The article, entitled "Linking Nursing Workload and Performance Indicators in Ambulatory Care" appeared in the January/February 2006 issue of Nursing Economic$. It describes how the STVHS's division that encompasses its ambulatory care and primary care clinic developed a process to link staffing/workload indicators with performance indicators. The two nurses became interested in the subject through their involvement with the American Academy of Ambulatory Care Nursing, an organization in which Swan serves as president and Griffin as a board member.

Because ambulatory care takes place in a multitude of settings with a wide variety of patients, Swan says, no single staffing model has been developed to help nurse leaders demonstrate and justify staffing levels with hard data. Griffin says the ambulatory care division adapted a model developed by the STVHS's patient quality improvement coordinator for use in its inpatient setting. Swan and Griffin hope nurse leaders will use the model developed by the STVHS to demonstrate links between staffing and patient outcomes and illustrate the value of ambulatory care nursing.

"So, rather than (staffing levels) being purely financially driven or driven by the intuition of nurse leaders," Swan says, "they wanted to say: 'Here is data that supports this kind of RN staffing.' "

Ambulatory care nurse-sensitive performance indicators are things nurses can influence in caring for their patients, Swan says, including pain management, patient education, and health screenings. Workload indicators included understaffing rates, vacancy rates, and adequacy of support services. Griffin and Swan matched these indicators to Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards and analyzed trends and opportunities for improvement.

Data from performance and workload indicators are given a score and summarized on a weighted grid sheet. Data are then divided into three categories: delighted, acceptable, and suboptimal. Support services also are analyzed. The resulting one-page report produces an overview of staffing and care outcomes related to nursing. Reports are submitted to the nursing quality management group and hospital administrators on a quarterly basis.

"It's really a process put in place backed up by data," Griffin says, "and what happens is every quarter different clinics submit data of how they're doing with clinical indicators and how they're doing with workload indicators."

The resulting data revealed opportunities for improvement in areas such as staff, skill mix, education or training, equipment, workflow, retention/recruitment, equipment enhancements, reorganization of workflow, and use of ancillary staff.

Among the changes that resulted from the process was an increase in staffing in primary care clinics, changes in staffing mix to include nurse practitioners and physician assistants, and acquisition of additional space for things like interviewing patients in private. Other changes included the creation of crossover positions such as an LVN/phlebotomy position in smaller clinics, purchasing additional computers and printers for nurses, and buy-in from top management on new staffing models for clinics.

Clinics that added staff and changed workflow processes improved their performance. One change in workflow process, Griffin says, involved eliminating the need for nurses to conduct exit interviews on every patient.

"We made an agreement with the physicians that for the patient that was relatively uncomplicated they would exit those patients themselves and the only patients that would go back to the nurses were the patients that were more complicated or who needed more in-depth instruction," says Griffin.

Other changes included conducting in-depth triage to reduce waiting times, making sure everyone starts work on time so patients can be seen as scheduled, and stocking all examination rooms with the same equipment so physicians don't have to search for things.

"The overall (trend) was that the nurse leaders were able to achieve buy-in from the top management on looking at different types of staffing models for various clinics," Swan says. "Their intent wasn't purely to increase RN staffing, it was to look at a complement of factors that influenced quality."

One of the best results to come from the project, Griffin says, is a change in the way administrators perceive ambulatory care nurses. The information derived from their efforts has made the contribution that nurses make to quality care visible throughout the system.

"The administrative side of the house didn't necessarily see the value of nursing in ambulatory care, and now they do," says Griffin."

The model developed by the STVHS isn't designed to convince administrators to spend more money, Swan says. It's to help administrators get the most for their staffing dollar and put together the right mix of people who can provide the best possible care. It's also designed to improve workflow and, therefore, cost effectiveness and to demonstrate the need for new technology that adds to what Swan describes as the "quality equation."

A "healthy tension" exists between providers and administrators, Swan says, as those charged with providing care interact with those charged with watching the bottom line.

"(Administrators) prefer to be making decisions based on knowledge and data, something concrete," says Swan. "They want to know: 'What are the facts? What supports this, and if I do this what are the outcomes going to be?' "

Scott Williams is a freelance writer.